Summary of October 1st, 2020 ICD-10 Code Updates

By Staci Booth
CPC, CCS, CRCR, Ahima Certified ICD-10 CM/PCS Trainer, Director of Coding Education, Appeals, QA, and Ensemble Health Partners Official “Queen of Codes”.

DRG Updates

  • 018 = CAR T-cell Immunotherapy (NEW DRG)
  • 019 = Simultaneous Kidney/Pancreas Transplant with Hemodialysis
  • 140-145 = Head, Neck, ENT Procedures (129-134 were removed)
  • 521, 522 = Hip Replacement with PDX of Hip Fracture
  • 650, 651 = Kidney Transplant with Hemodialysis
  • MS-DRG 014, 016, 017 housed bone marrow procedures that should have been in a medical DRG instead of surgical. This has been corrected.
  • Procedure codes 037H04Z, 037J04Z, 037K04Z, 037L04Z, 037M04Z, and 037N04Z now fall under MS-DRG 034, 035 and 036. They were previously under 037, 038 and 039. These procedures represent open carotid artery dilation using an intraluminal device. Additionally, we spoke about the 36 new codes that were added under MS-DRGs 252, 253 and 254.
  • Procedure codes 02L70CK, 02L70DK, and 02L70ZK now fall under MS-DRG 273 and 274. They were previously under 250 and 251. These represent left atrial appendage insertion.
  • T82.41XA, T82.42XA, T82.43XA, and T82.49XA now fall under 673-675 and 698-700 instead of 314-316.
  • DRG 673-675
    • Added E09.22, E10.22, E11.22, and E13.22 secondary to N18.5/N18.6
    • Added T86.11, T86.12, T86.13, and T86.19
    • Deleted I12.9, I13.10, N18.1, N18.2, N18.3, N18.4, and N18.9 as a PDX.
    • 06H00DZ, 06H03DZ, and 06H04DZ are no longer considered operating room procedures

ICD-10-PCS Guideline Updates

  • New guideline B3.18 – Excision or resection followed by replacement
  • New guideline B5.2b – Percutaneous endoscopic approach with extension of incision
  • Guidelines B3.1b revised – removed the exception for mastectomy followed by breast reconstruction
  • Guideline B3.10c revised – statement changed to “If an interbody fusion device is used to render the joint immobile (containing bone graft or bone graft substitute), the procedure is coded with the device value Interbody Fusion Device”

ICD-10-CM Guideline Updates

  • Guideline 14 revised – they added “Patient self-reported documentation may also be used to assign codes for social determinants of health, as long as the patient self-reported information is signed-off by and incorporated into the health record by either a clinician or provider.”
  • Diabetic medication revision – they added “If the patient is treated with both insulin and an injectable non-insulin antidiabetic drug, assign codes Z79.4, Long-term (current) use of insulin, and Z79.899, Other long term (current) drug therapy. If the patient is treated with both oral hypoglycemic drugs and an injectable non-insulin antidiabetic drug, assign codes Z79.84, Long-term (current) use of oral hypoglycemic drugs, and Z79.899, Other long-term (current) drug therapy.”
  • Guideline 9.a.3 revised – They changed the sequencing rule to state “For patients with both acute renal failure and chronic kidney disease, the acute renal failure should also be coded. Sequence according to the circumstances of the admission/encounter.”
  • Guidelines 10.e. added – Added guidelines for vaping-related disorders
  • Guidelines 21.c.6 revised – changed to include a COVID-19 scenario
  • Guidelines related to COVID-19 added – Guidelines from April were officially added. There were no new changes except that they clarified that Z20.828 should be used during the pandemic for those who receive testing but are found to be negative.

ICD-10-PCS Coding Updates

  • 556 new ICD-10-PCS codes
  • Surgery changes
    • 0*H**1Z – Insertion of radioactive elements (additional digits specify location and approach)
    • 0*F*3Z* – Fragmentation of various arteries and veins (many are percutaneous ultrasonic) ◦ 02173J6 – Percutaneous bypass of the left atrium to right atrium, using a synthetic substitute
    • 0F1D*** – Bypass pancreatic duct to stomach (additional digits specify device and approach)
    • 02UG3JH – Supplement mitral valve with synthetic substitute, transapical, percutaneous
    • 0QP**5Z – Removal of external fixation device (additional digits specify location and approach)
    • 0*G**3Z – Fusion of joint with sustained compression internal fixation device (additional digits specify location and approach)
    • 0JH**YZ – Insertion of other device (additional digits specify location and approach)
    • 0VY*0Z* – Transplantation of Scrotum/Penis (additional digits specify substitute type and location) ◦ 0W1G*J6 – Bypass peritoneal cavity to bladder with synthetic substitute (additional digit specifies the approach)
    • 0W9J*** – Drainage of pelvic cavity (additional digits specify device and approach)
    • 10D2*ZZ – Extraction of products of conception, ectopic (additional digit specifies approach)
    • 302**C0 – Transfusion of autologous hematopoietic stem/progenitor cells, genetically modified (additional digits specify site and approach)
  • Other changes
    • 4A0 – Measurement
      ◦ 5A09 – Assistance with respiratory ventilation (nasal)
    • 8E02XDZ – Spectroscopy
    • Other Imaging changes beginning with BF5 and BW5
    • Brachytherapy updates for GammaTile™ and other new therapies
    • IORT updates under D0Y
  • New technology
    • Cerebral embolic filtration under X2A
    • Supplement (mechanically expandable) under XNU
    • Introduction of new technology, including COVID-19 therapies under XW0
    • Transfusion of convalescent plasma and immunotherapy under XW1 and XW2
    • Measurement of infection under XXE
  • Remember to watch for the correct approach (this can change your DRG)

ICD-10-CM Updates

  • Multiple instances of Excludes 1 changing to Excludes 2
  • Multiple codes removed and more specific codes added. Those that are CC/MCC include:
    • A84.81 – Powassan virus disease
    • A84.89 – Other tick-borne viral encephalitis
    • B60.0* – Babesiosis specificity
    • D57 – Sick cell specificity
    • D59.1* – Autoimmune hemolytic anemia specificity
    • D84.8 – Immunodeficiency specificity
    • D89.8 – Cytokine release syndrome specificity
    • E70 and E74 – Deficiency specificity
    • G11.1* – Ataxia specificity
    • G40.83* – Dravet syndrome specificity
    • G71.2* – Myopathy specificity
    • G96.0* – Cerebrospinal fluid leak specificity
    • G97.8* – Intracranial hypotension
    • J82.8* – Eosinophilia
    • K20 and K21 – esophagitis specificity (those with bleeding are MCC)
    • M80 – Osteoporosis specificity
    • N00-N07 – Glomerulonephritis specificity
    • P91.82* – Neonatal cerebral infarction
    • T86.84** – Corneal transplant specificity
  • F10-F19 – New codes for alcohol and drug abuse with withdrawal (many are CC)
  • U07.1 – COVID-19 code officially added
  • U07.0 – Vaping-related disorder officially added

Webinar Question and Answer Recap

  1. What is the difference between Excludes 1 and Excludes 2?
    1. Excludes1 = The two conditions cannot be present at the same time and therefore should not typically be coded together.
    2. Excludes2 = The patient has two conditions that are most likely not related, therefore they can be coded separately. The exception would be if the physician states there are related.
  2. What does “sustained compression device” mean?
    1. Here is more information from the Final Rule:
    2. “Stryker, Inc., submitted an application for new technology add-on payments for the SpineJack® Expansion Kit (hereinafter referred to as the SpineJack® system) for FY 2021. The applicant described the SpineJack® system as an implantable fracture reduction system, which is indicated for use in the reduction of painful osteoporotic vertebral compression fractures (VCFs) and is intended to be used in combination with Stryker VertaPlex and VertaPlex High Viscosity (HV) bone cement.”
  3. What is the difference between CKD 3a and CKD 3b? Did they split other CKD stages out?
    1. They did not split out any other stages.
    2. Stage 3 CKD means there is an eGFR between 30 and 59.
    3. An eGFR between 30 and 59 means that there is some damage to the kidneys, and they are not working as well as they should.
    4. Stage 3 is separated into two stages:
      1. Stage 3a means you have an eGFR between 45 and 59
      2. Stage 3b means you have an eGFR between 30 and 44Source:
  4. Do encoder and host system updates take effect automatically on October 1st?
    1. Not necessarily
    2. Each host system and encoder system have an update process. Typically, this requires testing prior to a roll out.
    3. The host system and the encoder usually have to work together to set up that date, so the changes coincide with each other
  5. If the colonoscopy pathology report says eosinophilia, would you code it to the K chapter?
    1. For an outpatient account, yes, you could review the pathology report.
    2. For an inpatient account, you would need to confirm with the physician before assigning a diagnosis that was only documented on the pathology report.
  6. Is fragmentation taking the place of extirpation for a thrombus?
    1. It is not.
    2. These codes are specifically for percutaneous ultrasonic fragmentation.
    3. Here is their rationale
      1. The commenters are correct that there are different types of devices available in the treatment of pulmonary embolism (PE) and deep venous thrombosis (DVT).
      2. The commenters are also correct that some devices remove matter (clot, thrombus, etc.) while others fragment (break up) matter, with or without the use of thrombolytics. Under the ICD-10-PCS procedure classification system there are two root operations, extirpation and fragmentation, specifically defined as:
        1. Extirpation: Taking or cutting out solid matter from a body part
        2. Fragmentation: Breaking solid matter in a body part into pieces
      3. that are reported to describe the respective procedure that was performed. Because the EKOS™ device fragments matter, procedures performed utilizing this device are identified and described by the root operation Fragmentation
    4. More Information About Fragmentation From CMS
      1. We note that, as stated in prior rule making (84 FR 42148), our clinical advisors recognize that MS-DRGs 163, 164, 165, 166, 167, and 168 may warrant further review and therefore, we plan to begin conducting this detailed review beginning with our FY 2022 MSDRG classification analysis of claims data and determine what modifications may need to be considered for future rulemaking.
      2. See pg. 382 of the Final Rule
  7. Please clarify the Z79.4 and the Z79.899, is that with the injectable only?
    1. Z79.4 would be used for Long-term use of insulin
    2. Z79.84 is for Long-term use of oral hypoglycemic drugs
    3. Z79.899 would be used for Long term use of other drugs not included in the other Z79 codes
  8. What is a CC/MCC? What is an MDC?
    1. CC – complication or comorbidity
    2. MCC – major complication or major comorbidity
    3. MDC – Major diagnostic category (categories that MS-DRGs are placed into)
    4. They both show the resources might have been more intensive for inpatients with an MS-DRG payer.
    5. This is why it is crucial that for CC and MCC diagnoses, we have the proof to back up those diagnoses. We wouldn’t want to code a CC or MCC that didn’t actually impact the resources/care during the stay (think of something on a problem list that wasn’t really treated)
  9. When the provider documents and confirms alcohol abuse, rather than alcohol dependence, with alcohol withdrawal, do not assign a code for withdrawal, code only alcohol abuse. Will the handbook be updated along with the code changes??
    1. In the coding handbook it has:
      1. Alcohol withdrawal is characterized as alcohol dependence.
      2. ICD-10-CM does not classify alcohol withdrawal with alcohol abuse.
    2. I cannot answer if the handbook will be updated but, here is some more information.
    3. I still think we need a physician to state that the alcohol abuse (drug abuse) is causing the withdrawal.
    4. The verbiage will no longer be valid given the description of these new.
    5. Now we have a code to capture the scenario, before we did not so the coding advice was necessary before.
  10. Was there a change that GCS can only be captured for TBI (not for CVA or other situations anymore)?
    1. We are monitoring the changes around this as we have heard there may be clarification coming out about this.
    2. They did make a change to verbiage, calling out that these codes were for TBI.
    3. Of note, they are not considered MCC in many scenarios. You can see all of those here: – PDX Collection 0515
      We will provide updates as they come.
  11. Does a physician have to write “intoxication” for ETOH use d/o with intoxication or can I get that from the nursing notes?
    1. No, we cannot use nursing notes for that diagnosis.
    2. The physician would specifically have to state that the patient was intoxicated.
  12. Can you provide a reminder about common flu coding tips?
    1. If they are being vaccinated, don’t forget Z23. Use that search function in your encoder if you are using computer assisted coding.
    2. What type of influenza does the patient have? For confirmed cases, if the documentation is available, the specific type of influenza may have a specific code.
    3. What manifestations does the patient have? Pneumonia is a common one. Remember that there are options in your codes for the complications associated with influenza.

COVID-19 Questions

  1. Should we use the new technology codes for COVID-19 treatments? They shouldn’t change the DRG.
    1. Yes, the drug administration code should be coded when given (only needs coded once)
    2. These codes are to be used when the patient is being treated for COVID-19
      1. Remdesivir
      2. Sarilumab
      3. Tocilizumab
    3. The same goes for transfusion of convalescent plasma
    4. Make sure to use the most specific new technology code relevant to the stay
  2. How do we code MIS-C (multi-inflammatory syndrome) for a patient that has COVID-19?
    1. Currently, this codes to M35.8 (other specified systemic involvement of connective tissue)
    2. Please note that there have been proposals sent to CMS/CDC to possibly add a code specific to MIS-C but that hasn’t happened yet.
  3. Will code Z03.818 become obsolete on October 1st?
    1. No, it can still be used for other scenarios when there is observation for suspected exposure to any other biologic agent.
  4. Should Z01.84 for antibody testing be used as a secondary? We get an edit when doing so.
    1. Z01.84 is for general immunity testing (not only COVID-19). The only note on the code states that it should not be used with Z01.82, Z02, Z03, Z00.0.
  5. How would we now code pre-admission testing that includes COVID-19?
    1. We would use Z20.828 until the pandemic is no longer considered current.
  6. A doctor can state the patient has Covid and we are to take it as confirmed? What if the doctor states the patient has Covid, but the labs result says not detected?…
    1. I personally would ask CDI to query based on conflicting documentation, just to be sure in the case of an insurance audit.
  7. Did you say that if the patient tests negative for COVID-19 that Medicare will not pay the 20% increase for the test? and when is that going to start?
    1. That is correct. Here is a link to the CMS article – I recommend monitoring it for revisions. It became effective on September 1st.
  8. We are seeing providers using U07.1 as a diagnosis sometimes 4 5 months after the positive test. If not being actively treated for Covid or if not a follow-up of Covid, U07.1 should not be coded, is that correct?
    1. I would recommend a query if there is no positive test result and the physician says that it is positive.
      That being said, many organizations are creating policies specific to this, so it is always important to follow the policy from your organization.
  9. Would the new convalescent plasma codes be used for covid-19 patients?
    1. Yes, that is correct. Here is an FDA article about that: fda-issues-emergency-use-authorization-convalescent-plasma-potential-promising-covid-19-treatment
  10. What is the correct coding for a pre-op visit for COVID-19 screening? Would Z01.812 and Z20.828 be correct?
    1. Yes, until we are told that the pandemic is lifted, that would be the correct coding for a pre-op (the Z code could vary depending on other types of pre-op testing that are done)